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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210111734
Report Date: 09/02/2025
Date Signed: 09/02/2025 03:33:51 PM

Document Has Been Signed on 09/02/2025 03:33 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:WILD FLOWERS RCFEFACILITY NUMBER:
210111734
ADMINISTRATOR/
DIRECTOR:		ALLEN, C. ELIZABETHFACILITY TYPE:
740
ADDRESS:256 SUNSET PARKWAYTELEPHONE:
(415) 264-7399
CITY:NOVATOSTATE: CAZIP CODE:
94945
CAPACITY: 6CENSUS: 4DATE:
09/02/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Gladys Flores, DesigneeTIME VISIT/
INSPECTION COMPLETED:
01:20 PM
NARRATIVE
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License Program Analyst (LPA) Hansen arrived unannounced to conduct an Annual Required inspection of the facility. LPA was welcomed by designee/staff Gladys Flores. Elizabeth Allen Licensee/Administrator was contacted by staff although unable to attend today’s inspection, authorized designee to sign for today’s visit. Facility is single story with 5 bedrooms that Novato Fire has granted clearance for 6 Non ambulatory residents. Facility has hospice waiver for 2. There is a total of 4 residents, 2 with a major neurocognitive disorder diagnosis and none on Hospice.

LPA toured the facility on 9/2/2025 at 8:45 AM with designee/staff Gladys Flores; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Exits were equipped with auditory devices which were working properly at the time of the visit. Fire Extinguisher was found to be last charged on 9/24/2024. Smoke detectors and carbon monoxide were found to be operational during the visit. Hot water temperature measured 106.3 to 116.6 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 2 out of 2 resident’s bathrooms while touring facility on 9/2/2025 at 8:45am. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked cabinet in the laundry/garage room; although bleach was observed under resident bathroom sink without lock (see pics & LIC809D).There was a supply of cleaners, hygiene products and paper products available for residents. The bathrooms designated for residents at the facility were supplied with individual towels and hand soap dispensers. Bathrooms were equipped with necessary grab bars, and slip-resistant mats, strips, or flooring in all bathtub and shower floors as required by Title 22 regulations.

Continue on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Shannan Hansen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/02/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 09/02/2025 03:33 PM - It Cannot Be Edited


Created By: Shannan Hansen On 09/02/2025 at 12:25 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: WILD FLOWERS RCFE
FACILITY NUMBER: 210111734

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87606(c)
Care of Bedridden Residents
(c) To accept or retain a person who is bedridden, other than for a temporary illness or recovery from surgery, a licensee shall obtain and maintain an appropriate fire clearance as specified in Section 87202, Fire Clearance.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, interview with Designee and record review of 602A, the licensee did not comply with the section cited above in retaining a bedridden resident without an approved bedridden fire clearance, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/03/2025
Plan of Correction
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Facility agrees to submit an updated LIC200 and Faciilty sketch as described in the LIC809 by POC due date, 9/3/2025.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Shannan Hansen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/02/2025 03:33 PM - It Cannot Be Edited


Created By: Shannan Hansen On 09/02/2025 at 12:37 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: WILD FLOWERS RCFE
FACILITY NUMBER: 210111734

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)(1)
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. (1) Disinfectants, cleaning solutions, and poisonous substances shall be stored in areas separate from food supplies as specified in Section 87555, General Food Service Requirements.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA & designee's observation during tour of facilty the licensee did not comply with the section cited above in finding a spray bottle of bleach under residents bathroom sink which poses/posed a potential health, safety or personal rights risk to persons in care..
POC Due Date: 09/12/2025
Plan of Correction
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Licensee / Administrator will provide an LIC 9098 Proof of Corrections self certifying that Regulation 87309(a) was reviewed with all staff by POC due date of 9/12/2025.
Type B
Section Cited
CCR
87465(h)(6)

87465 (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible a record of centrally stored prescription medications for each resident...: This requirement was not met as evidenced by:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on ovesrvations by LPA & designee during record review of CMSR, the licensee did not comply with the section cited above in 2 out of 2 residents did not ensure that there was a completed LIC622 or similar document with all of the regulatory information required. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/12/2025
Plan of Correction
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Licensee agreed to conduct all staff training in medication administration to submit CCL with centrally store medication log for all residents in care by plan of correction date (POC) 09/12/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Shannan Hansen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2025


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: WILD FLOWERS RCFE
FACILITY NUMBER: 210111734
VISIT DATE: 09/02/2025
NARRATIVE
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Continued from LIC809

All bedrooms have lighting & appropriate furnishings. At the time of the visit LPA observed that 1 out of 4 residents (R1)’s Medical Assessment (LIC602A) indicates admitted to facility with Bedridden diagnosis & not able to independently transfer (has and is not under Hospice care). Facility does not have fire clearance for bedridden residents (see LIC809D).



A review of four resident & four staff records as well as two resident’s medications records was conducted. LPA reviewed resident’s files at 10:00 AM on 9/2/2025 and learned that 4 out of 4 residents have a current reappraisal on file. In addition, 4 out of 4 residents have required physician’s report.

Medications were centrally stored in a locked medication cabinet in the dining room of the facility; although there were additional medications pre-poured stored in drawer next to centrally stored without being locked (see LIC809-D). The Medications of 2 out of 2 residents were found to be given according to physicians’ directions. Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to not be complete and accurate on 9/2/2025 (see LIC809D).

LPA reviewed a sample of staff records at 11:00 AM on 9/2/2025 and learned that all facility staff present and other individuals who require caregiver background checks have received criminal record clearances or exemptions. In addition, Direct care staff at the facility have received the additional training requirements. LPA was presented with proof of CPR & 1st Aid certification for staff that files were reviewed. Elizabeth Allen Administrator Certificate #7003030740 expires on 10/21/2025. Disaster Drills have been conducted quarterly with the last conducted on 7/8/2025.

In order to request a bedridden fire clearance, the following documents are to be sent to CCL no later than 9/3/2025:

An LIC200 filled out entirely showing 1 bedridden in section 10B & An updated facility sketch identifying bedridden room.

Appeal of Rights Given.


The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

LPA Hansen is requesting Licensee to submit the following documents to CCL by 9/19/2025:

LIC 308 Designated


LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Resident’s
Copy of Administrator Certificate
Copy of Certificate of Liability Insurance
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Shannan Hansen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2025
LIC809 (FAS) - (06/04)
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